What are co-occurring disorders?

Overview

Persons who have been diagnosed with a substance abuse disorder are twice as likely to also have a serious mental illness, compared with the general population. Moreover, the reverse holds true—people diagnosed with a serious mental illness are twice as likely to also have a substance abuse disorder. When two (or more) separate disorders occur simultaneously or concomitantly in the same person, they are said to be comorbid or co-occurring, although one illness does not directly cause the other.

Despite this, the two disorders do interact, and each can affect the course and outcome of the other. Substance abuse disorders and serious mental illnesses are caused by overlapping factors, such as underlying deficits in the brain and genetic vulnerabilities, and both affect similar neurotransmitters and signaling pathways. Substance abuse can acerbate or trigger psychosis and mood and affective disorders; worsening or untreated mental illness can intensify the drug or alcohol problem.

Experience has shown that mental health issues tend to surface before the onset of substance abuse, which then becomes a conscious or subconscious form of self-medication to alleviate symptoms of mental anguish. People with COD have a poorer prognosis and higher rates of drug relapse, and they are more prone to treatment noncompliance and violent behaviors. Risk factors for having CODs include family history of substance use; multidrug use; antisocial personality disorder; being a young, single, adult male; having a lower level of education; homelessness; incarceration; and limited access to treatment.

Evolving Evidence

The association between substance abuse disorder and serious mental illness has been well established, supported by several major studies first conducted during the late 1990s. These studies include the landmark Epidemiologic Catchment Area Study and the National Comorbidity Survey, both sponsored by the National Institute of Mental Health. Also, the Substance Abuse and Mental Health Services Administration (SAMHSA), part of the US Department of Health and Human Services, issues its annual National Survey on Drug Use and Health (NSDUH), which provides data on health and the use of tobacco, alcohol, and illicit drugs in the United States.

According to the NSDUH, 2.5 million adults aged eighteen years or older had a COD in 2008. In general, adults with a past-year serious mental illness had higher rates of past-year illicit drug use (30.3 versus 12.9 percent), higher rates of past-year cigarette use (50.5 versus 28.5 percent), higher rates of heavy alcohol use (11.6 versus 7.3 percent), and higher rates of binge drinking (29.4 versus 4.6 percent), compared with those without a serious mental illness.

Among adults with past-year major depressive episode (MDE), 20.3 percent abused or were dependent on alcohol or illicit drugs, compared with 7.8 percent without MDE. More specifically, adults with MDE had higher rates of past-year illicit drug use (27.2 versus 13.0 percent), past-thirty-day heavy alcohol use (9.6 versus 7.1 percent), and past-thirty-day cigarette use (29.1 versus 15.2 percent), compared with those without MDE. Adults with past-year serious psychological distress (SPD) had higher rates of past-thirty-day illicit drug use (19.6 versus 7.3 percent, and, excluding marijuana, 12.3 versus 2.9 percent), heavy alcohol use (12.1 versus 7.3 percent), binge drinking (30.9 versus 24.6 percent), and cigarette use (47.6 versus 24.5 percent), compared with adults without SPD.

Furthermore, the NSDUH reports that two million youths aged twelve to seventeen years had MDE in 2008, and of that figure, 21.3 percent had illicit drug or alcohol dependence or abuse, indicating that there were 426,000 youths with CODs in 2008. For those who did not have MDE, the rate of dependence or abuse was only 6.4 percent. Youths with MDE also had higher rates of illicit drug use (37.4 versus 17.2 percent), past-thirty-day cigarette use (3.6 versus 1.8 percent), and past-thirty-day heavy alcohol use (3.4 versus 1.8 percent), compared with those without MDE.

Treatment Approaches

Researchers now have a better understanding of the prevalence of CODs, of the specific issues related to CODs, and of how CODs affect treatment and treatment outcome. Of the 2.5 million adults with COD in 2008, 60.5 percent received treatment at a specialty facility, but only 11.4 percent received treatment at a facility equipped to treat both substance abuse disorders and serious mental illnesses. However, efforts to provide targeted treatment for both disorders concurrently is gaining favor, as mental health professionals realize the need to address the interrelationships among the two disorders and begin to focus more attention on their shared neurobiological aspects.

Integrated treatment
involves combining COD treatment with a primary treatment relationship or service setting. The intention is to treat the whole person. SAMSHA states that integrated COD treatment “is an evidence-based approach to care, which recognizes that individuals go through different stages on their way to recovery.” These stages include engagement (establishing a working alliance), persuasion (forming a trusting relationship), active treatment (seeing the problem and making positive changes), and relapse prevention (creating a relapse prevention plan and building on positive behaviors). Such practices as integrated screening and assessment techniques, treatment planning strategies, motivational interviewing, cognitive-behavioral therapy, and peer support are part of the treatment program. Integrated stage-wise treatment is proving to be a viable path to recovery and is helping individuals with COD improve the quality of their lives.

Bibliography

Atkins, Charles. Co-Occurring Disorders: Integrated Assessment and Treatment of Substance Use and Mental Disorders. Eau Claire: PESI, 2014. Print.

Choi, Sam, Susie M. Adams, Siobhan A. Morse, and Sam MacMaster. "Gender Differences in Treatment Retention among Individuals with Co-Occurring Substance Abuse and Mental Health Disorders." Substance Use and Misuse 50.5 (2015): 653–63. Print.

Galanter, Marc, and Herbert D. Kleber, eds. Psychotherapy for the Treatment of Substance Abuse. Arlington: American Psychiatric, 2011. Print.

Hendrickson, Edward L. Designing, Implementing, and Managing Co-Occurring Treatment Services for Individuals with Mental Health and Substance Use Disorders. Binghamton: Haworth, 2006. Print.

Mignon, Sylvia I. "Treatment of Co-Occurring Disorders (Dual Diagnosis)." Substance Abuse Treatment: Options, Challenges, and Effectiveness. New York: Springer, 2015. 139–56. Print.

Smith, John. Co-Occurring Substance Abuse and Mental Disorders: A Practitioner’s Guide. Lanham: Aronson, 2007. Print.